Average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Canterbury Center during CMS and state inspections, most recent first.
Failure to Maintain Clean and Homelike Resident Rooms: Surveyors observed a bed pan left on a bathroom floor, trash debris on the floor, and overflowing trash cans in multiple resident rooms. A resident also reported a dirty bedside table that remained soiled on follow-up observation, and an RN confirmed it was soiled. NAs verified the rooms and bathroom areas needed cleaning, and one NA noted staffing was a bit low.
The facility failed to answer call lights in a timely manner and failed to follow a physician order for an x-ray. Residents reported repeated delays with call light response across shifts, and one resident’s call light was observed out of reach and left unanswered for an extended period during meal service. Another resident who fell and had pain after the incident had x-rays ordered for the knee, foot, and sacrum, but the sacrum x-ray was not completed as ordered.
Physician did not acknowledge multiple CP MRR recommendations for several residents. Issues included an incomplete diclofenac gel order, review of Florastor use without GI complaints, review of olanzapine and dual antidepressant therapy, and repeated insulin dose adjustment recommendations to reduce corrective lispro use. The DON and Administrator verified that the recommendations were not reviewed, acted on, or documented with rationale.
Late meal service with cold, tough food: Due to short staffing, the noon meal was delayed and trays were initially planned for room delivery instead of the dining room. Residents waited in the dining room while trays arrived late, some were cold after being sent to rooms and back again, and several residents reported the meat was too tough to cut or chew and the food was not appetizing.
Improper Food Storage in Kitchen and Nourishment Pantry: The facility failed to store food and utensils properly in the kitchen and nourishment room. Surveyors found an opened box of bacon left exposed to air, a ketchup container with a damaged lid exposing the condiment, utensils stored inconsistently in drawers, and a nourishment room refrigerator reading 48 degrees. The DM, FA, DON, and CRN acknowledged the findings.
A resident was observed during lunch with a NA standing over him while assisting with his meal. The DON verified that staff should assist residents with meals while sitting beside them, not standing over the resident.
A resident’s preference for no male caregivers was documented only in the special instructions section and was not incorporated into the care plan or active physician orders. The SSD stated she had never interviewed the resident about caregiver preferences, and the DON confirmed the directive was not properly reflected to alert all staff.
A resident who had capacity reported she had not received a shower in three weeks despite expecting showers twice weekly and stated her hair was greasy and she could not care for it herself. The care plan identified a need for substantial/maximal assistance with bathing, but it was not updated to reflect her preference for showers, and the bathing record showed she was receiving bed baths instead of showers; staff could not confirm that she had refused the showers.
Unsecured hazardous items and unlocked carts/doors: A resident had a spray bottle of disinfectant/cleaner on a bedside dresser, and housekeeping staff confirmed it was in the room. Surveyors also observed an unlocked, unattended HK cart near the DR, an unlocked door in the service hall, and an unlocked, unattended treatment cart near the resident lounge while residents were moving through the area; staff verified these items and doors should have been locked.
A resident was still wearing a wanderguard even though the order had expired, and the MAR documentation for daily placement and function checks was filed under an area showing the expiration. Staff had been recording the checks, but the chart orders were incorrect until the DON confirmed and updated them.
Insufficient Nursing Staffing and Delayed Call Light Response: Residents reported very long call light response times, with 12 of 13 resident council members stating waits were longer than 45 minutes most days. A surveyor also overheard a worker tell a resident the facility was short staffed and it was taking a long time to get to them, and the Administrator confirmed staffing issues.
The facility failed to complete the daily nursing staffing posting accurately when the required resident census was missing from the posted staffing data for two days. During an interview, an RN confirmed the census had not been documented.
A resident reported that sink water was too hot and required staff assistance to cool it, and a surveyor confirmed the water was uncomfortably hot during inspection. Water temperature checks in several rooms, conducted with the MD, revealed readings between 118 and 128°F, with the MD acknowledging the high temperatures. The facility did not adequately control water temperatures, resulting in an environment not free from accident hazards.
The facility did not complete required competency evaluations for five nurse aides, as confirmed by a review of staff files and an interview with the Consulting Administrator, who acknowledged that no competency records existed for these staff members in the past year.
Surveyors found that kitchen staff failed to document temperatures for the walk-in refrigerator and freezer, left a large box of cookie dough open in the freezer, and did not maintain cleanliness in the resident pantry, where expired oatmeal was also found. The ice machine was missing a required water filter, as confirmed by the Maintenance Director. These issues reflect lapses in kitchen sanitation, food storage, and equipment maintenance.
Staff failed to maintain infection control standards by mishandling clean linen, storing personal items and medications with linens, leaving soiled briefs in shared bathrooms, and placing trash and linen bags on the floor. Additionally, hand hygiene was not provided to residents before meals, dirty trays were mixed with clean ones during meal service, dinner trays were left out overnight, and laundry machine filters were not cleaned daily. These actions and inactions were confirmed by interviews with various staff members.
Multiple rooms and common areas were found with unfinished drywall, bulging and stained walls, cracked tiles, overflowing trash cans, and brown substances in bathrooms and on ceilings. Staff confirmed these issues, and a resident reported ongoing concerns about dark spots on the ceiling that had not been addressed despite repeated requests. The facility did not provide adequate housekeeping and maintenance services, resulting in an environment that was not clean, safe, or homelike.
Survey results were not posted in a location easily accessible to residents, families, or legal representatives, as required. Despite signage indicating the survey results were available in the lobby, they were not found there during multiple observations. The Administrator later located the survey book in the business office, confirming it was not accessible to those who needed it.
Multiple documents containing residents' personal and medical information, including names, diagnoses, medication lists, and controlled substance records, were found unsecured in a hallway wall file outside the nursing office. The DON confirmed the documents were placed with the blank side up, but they remained accessible to anyone in a high-traffic area.
A resident's discharge status was incorrectly documented in the MDS as discharge to a hospital, when in fact the resident was taken home by family with home health and medical follow-up arranged. The MDS Coordinator confirmed the error, resulting in an inaccurate assessment record.
A resident receiving oxygen therapy was repeatedly observed with her oxygen concentrator set at 4 L/min, contrary to a physician's order for 2 L/min by nasal cannula. Multiple observations and record reviews confirmed the oxygen was not administered as prescribed until staff intervention.
The facility did not update daily nurse staffing postings to reflect the actual hours worked by RNs, LPNs/LVNs, and CNAs for multiple days. The posted information did not match the hours worked by direct care staff, as confirmed by record review and staff interview.
Multiple cognitively intact residents reported that staff do not routinely offer evening snacks, and snacks are only provided if specifically requested, with limited options available. The Dietary Manager confirmed that only pre-ordered snacks or a small selection of snack cakes are accessible, and no additional snacks are available after the kitchen closes.
Garbage and used medical supplies were found scattered around the dumpster area with the lids left open. The Maintenance Director confirmed the presence of trash and medical supplies on the ground, potentially affecting all residents in the facility.
Surveyors found that two residents had uncovered urinary catheter bags visible to others—one in bed and another moving through the hallway in a wheelchair. Both residents' catheter bags were not covered, and staff confirmed the lack of covers, with one resident stating he had never been offered one.
Two residents were not provided with morning care and assistance according to their stated preferences, with one resident repeatedly receiving care much later than requested and another lacking documentation of her morning routine preferences. Staff did not consistently honor resident choices regarding waking time and morning care, and these preferences were not always reflected in care plans or records.
A resident's grievance form was not completed or logged, and the required written decision was not issued, contrary to the facility's grievance policy. The administrator confirmed that no completed copy of the grievance form could be found.
Staff failed to investigate and report injuries of unknown origin and allegations of neglect for two residents. One resident had unexplained bruising that was not investigated or reported as required by policy, and another resident's family reported skin damage and lack of bathing, but the facility delayed investigation and did not report the allegation to state authorities in a timely manner.
The facility did not promptly report or investigate two separate allegations involving suspected abuse and neglect. In one instance, a resident was found with an unexplained bruise, and the DON did not initiate an investigation or report the injury as required. In another case, a family member reported that a resident developed pressure ulcers and was not receiving regular baths; although the facility communicated with APS, it failed to report the incident and investigation results to the appropriate state authority within the required timeframe.
A resident was found with a large, unexplained bruise on her upper arm, which was not initially recognized or investigated by the DON. Although a NP later assessed the injury, the facility did not follow its policy to investigate or report the injury of unknown origin as required.
A resident did not receive showers or baths as ordered or preferred, with documentation showing only one shower and two bed baths provided in a 30-day period. The resident expressed dissatisfaction with her hygiene, and the administrator confirmed the lack of documentation for scheduled showers.
A dependent resident with incontinence was not assessed or provided incontinence care at the required intervals. The resident's MPOA reported frequently finding the resident soiled, and documentation confirmed that after an initial morning check, no further assessments were recorded. Staff acknowledged that checks should occur every two hours but did not follow this protocol.
Surveyors identified that for two residents, monthly medication regimen reviews by a pharmacist were not completed, and physician responses to pharmacist recommendations were missing. The DON confirmed that required documentation and physician follow-up were not available.
A resident with a history of malnutrition and weight loss did not receive her requested cereal and milk for breakfast on multiple occasions, despite repeated requests from her and her family and clear documentation on her tray ticket. Staff confirmed that kitchen errors led to the omission of requested items, requiring nursing staff to intervene.
The facility did not ensure all staff had thorough background checks, as required by Virginia state regulations. A nurse aide, employed since 2006, lacked a WV CARES eligibility letter, which became mandatory in 2016. The DON confirmed the absence of this documentation, despite the aide working prior to an illness. This issue was identified during a review of staff records.
The facility did not ensure RN coverage for eight consecutive hours daily, affecting all residents. On two occasions, no RN was scheduled or worked, as confirmed by the DON, who cited staffing shortages.
The facility failed to retain original staff postings for at least 18 months, as required. The deficiency was identified when the DON could not provide the original Staff Posting Sheets for the first quarter of 2024, affecting all 58 residents.
The facility failed to properly contain waste in the dumpster area, affecting multiple residents. Observations on three occasions revealed trash, including used gloves, masks, and cigarette butts, scattered around the dumpster and extending to the city road.
The facility failed to support resident self-determination by not adhering to shower preferences for several residents. One resident reported receiving showers only once every two weeks, while another experienced conflicts between shower schedules and preferred activities. Other residents were not given choices between showers and bed baths, and some had inconsistent shower availability. The DON acknowledged ongoing issues with shower schedules and documentation, contributing to the deficiency.
The facility failed to implement comprehensive care plans for several residents, leading to deficiencies in care. A resident on fluid restriction received excess fluids without a care plan, while another legally blind resident lacked a plan for daily activities. A resident with edema and another with dementia had no care plans for their conditions. Additionally, a resident with hemiplegia faced anxiety due to improper call light placement, which was not addressed in their care plan.
The facility failed to administer medications on time for several residents, including those with diabetes and gangrene, and did not complete required neuro checks after a fall. Additionally, a critical oxygen level was not reported to a physician for a resident with CHF and atelectasis. These deficiencies were confirmed by the DON and a registered nurse.
A medication cart was found unlocked and unattended, posing a potential hazard by allowing unauthorized access to medications. The DON confirmed the issue, and an LPN highlighted a faulty lock mechanism. Facility policy requires carts to be locked when unattended.
The facility failed to monitor and document side effects and behaviors for three residents receiving antianxiety and antidepressant medications. A resident with Alzheimer's and anxiety was not monitored for side effects of buspirone. Two other residents, one with depressive disorder and another receiving lorazepam for seizures, also lacked proper documentation of side effects and behaviors, as confirmed by the DON.
The facility did not provide a substantial evening snack to all residents, affecting those without a dietary order or the ability to request one. Residents reported the lack of snacks during a council meeting, and an LPN confirmed snacks were only given to those with a diagnosed need. A tour showed limited snack options.
The facility failed to maintain an effective infection control program. A resident had uncleanable gauze and tape on their wheelchair, and a physical therapist assistant did not use PPE while treating a resident under contact precautions for CDiff, using hand sanitizer instead of soap and water.
The facility failed to assist a resident with personal grooming, resulting in noticeable facial hair, and did not serve meals simultaneously to residents at the same table, causing delays. Additionally, a resident was not asked about voting in an upcoming election, despite its importance to him.
A resident with limited mobility due to a stroke expressed that his call light was often out of reach, as it was placed on his nondominant side. An LPN confirmed the call light was not accessible, acknowledging the resident's need for it to be on the right side.
A resident with a legal guardian experienced a fall, but the facility failed to notify the guardian, only attempting to contact the resident's son. The resident lacked capacity for medical decisions, and the WV DHHR was appointed as the legal guardian. Despite this, the facility did not inform the guardian of the fall, as confirmed by staff interviews and record reviews.
A resident's privacy was compromised during catheter care when a nurse aide failed to close the door and blinds. Additionally, an elopement binder with sensitive resident information was left unattended in the lobby, accessible to the public. The facility administrator acknowledged the privacy issue.
A resident's grievance about a missing wheelchair was not properly documented or resolved by the facility. Despite multiple reports to staff, the resident did not receive follow-up or resolution, and the social worker failed to track the grievance, assuming it was resolved after the wheelchair was initially found.
Failure to Maintain Clean and Homelike Resident Rooms
Penalty
Summary
The facility failed to keep resident rooms and bathrooms in a clean, comfortable, and homelike condition in multiple rooms observed during the survey. In one room, a bed pan was found on the bathroom floor and trash debris was observed on the floor between and under the beds; a NA verified the bed pan should have been off the floor and the room cleaned, stating that on weekends housekeeping is usually scheduled with one person. In another room, the trash can had trash overflowing under the sink and in the bathroom, and the NA verified the room and bathroom needed cleaning. In a third room, the surveyor observed an overflowing trash can with trash debris and a soiled brief in it; the NA verified the trash was overflowing and stated the brief should not have been in the trash can, adding that staffing was a bit low. For Resident #4, the resident stated her bedside table was dirty and never got cleaned, and the surveyor observed the bedside table was soiled and needed cleaning. On a later check, the room floor was dry and appeared cleaned, but the bedside table remained soiled, and an RN confirmed it was soiled and said it would get cleaned.
Delayed Call Light Response and Failure to Follow Physician Orders
Penalty
Summary
The facility failed to ensure call lights were answered in a timely manner and failed to ensure treatment and care were provided in accordance with physician orders. Survey findings included repeated grievances and resident council concerns over several months about long call light response times on day, evening, night, and early morning shifts, including reports that call lights were slow to be answered, went unanswered, or were turned off without assistance until later. During observation, Resident #8’s call light was found on the floor between the side rail and mattress, out of reach, and remained unanswered for an extended period while the resident stated it had been on since 12:10 PM. Later the same day, the resident’s call light was again observed on and remained unanswered for a prolonged period while meal service was occurring and no staff were observed on the unit. Resident #39 reported that call lights take a long time to be answered and that sometimes the resident wets herself while waiting. Resident #79 reported that call lights take a long time to be answered and that staff told the resident they were short staffed. Resident #41 also reported that staffing seemed insufficient and that aides and nurses were busy. Resident #4 reported a fall from a shower chair and stated the facility waited three days to obtain an x-ray. Record review showed that after the fall, the physician ordered x-rays of the right knee, right foot, and sacrum due to pain. The x-rays were obtained for the right knee and foot, but the sacrum x-ray was not completed as ordered. The DON stated she was not sure why the sacrum x-ray was not done and later stated she could not determine why it was omitted.
Physician Did Not Acknowledge Consultant Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to ensure that consultant pharmacist recommendations from monthly medication regimen reviews were acknowledged by the physician for multiple residents. For Resident #43, the consultant pharmacist twice recommended updating the diclofenac gel 1% order to specify the amount of grams to be applied, but the physician did not respond to or acknowledge either recommendation. During interview, the DON stated she did not know why the recommendations had not been acted on and said she had come to the facility in December 2025. For Resident #54, the medical record showed monthly drug regimen review responses without physician review, action, or rationale. The consultant pharmacist recommended considering stopping Florastor twice daily because there were no noted GI complaints, but no physician response was documented. For Resident #56, the consultant pharmacist recommended review of olanzapine use on admission and noted that the resident was receiving both escitalopram and trazodone, stating that use of more than one antidepressant had not been shown to be more effective than a single agent and could increase side effects; the Administrator verified that the physician did not review the recommendation or note any action or rationale. For Resident #4, the consultant pharmacist repeatedly recommended increasing glargine insulin or routine lispro doses to lessen the need for corrective lispro insulin, and the facility had no evidence that these recommendations were acknowledged.
Late meal service with cold, tough food
Penalty
Summary
Food and drink were not kept palatable, attractive, and at a safe and appetizing temperature during the noon meal service. On 07/12/26, kitchen staff reported that because the facility was short-staffed, residents were initially not going to be served in the dining room at the usual noon time. The dining room was then opened after the state surveyors were present, and the Dietary Manager had already placed the usual dining room meal tickets back in the stack for room delivery. Residents were observed waiting in the dining room at 12:25 PM, and the first trays were not served until 12:40 PM, which was 40 minutes late. Resident #47 refused the tray because she could not cut or chew the meat, and Resident #44 did not receive a tray until 12:50 PM. Later observations showed additional trays arriving after being sent to residents’ rooms and then back to the dining room, with some trays sitting on the counter. Resident #11 received an extra tray that was cold and stated it was too cold to eat; it was then reheated and served again at 1:35 PM. Resident #37 stated the tray was cold and the meat was too tough, saying she did not want to break her teeth on it. Other residents also reported that the meat was tough, the mashed potatoes were runny, and the food was often cold because trays took a long time to be passed. The Dietary Manager stated the dining room had originally been planned to be closed for the noon meal because the facility was short staffed, and the Administrator and Corporate RN later acknowledged the noon meals had been served late with cold and tough food in the dining room.
Improper Food Storage in Kitchen and Nourishment Pantry
Penalty
Summary
The facility failed to properly store food in accordance with professional standards in both the kitchen and the nourishment pantry. During an initial kitchen tour, the Dietary Manager acknowledged an opened box of bacon in the walk-in cooler that was not sealed and was left open to air, a ketchup container in the refrigerator with a hole in the corner of the lid exposing the condiment to open air, and two utensil drawers where scoops were not stored all in the same direction. During a nourishment room walkthrough, the Dietary Manager found the refrigerator thermometer showed an internal temperature of 48 degrees and stated she would request maintenance to check it. The facility policy on food storage stated that all foods will be stored wrapped or in covered containers, labeled and dated, and arranged to prevent cross contamination. The Facility Administrator, DON, and Corporate RN later acknowledged the exposed bacon, open condiment, incorrectly stored utensils, and the 48-degree refrigerator temperature.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to treat a resident with respect and dignity during the lunch dining experience. During meal service, Nurse Aide #66 was observed standing over Resident #54 while assisting him with his lunch meal. The Director of Nursing later verified that staff should assist residents with meals while sitting beside them, not standing over the resident.
Care Plan Did Not Reflect Resident’s Preference for Female Caregivers
Penalty
Summary
Resident #38 had a documented preference for no male caregivers in the special instructions, but this preference was not integrated into the resident’s primary care goals or active physician orders. Review of the comprehensive care plan and physician orders showed that the no-male-caregiver instruction remained only in the special instructions section. During interview, the Social Service Director stated she had never interviewed Resident #38 about her care-giver preferences, and the Director of Nursing confirmed that the directive for no male caregivers was not properly reflected in the care plan or physician orders to ensure all staff were alerted to the request.
Failure to Provide Requested Bathing Assistance
Penalty
Summary
The facility failed to ensure one resident received the assistance needed with activities of daily living, specifically bathing. Resident #4 stated during interview that she had not had a shower in three weeks and said she was supposed to receive showers every Monday and Friday. She became teary-eyed and stated that her hair was greasy and she could not do it by herself. The resident had capacity to make medical decisions and reported a preference for showers. Record review showed the resident’s care plan identified a need for assistance with ADLs, including bathing, and directed staff to provide substantial/maximal assistance for bathing. However, the base care plan had not been updated to reflect her bathing preference for showers. Bathing documentation provided by the facility showed that the resident was receiving bed baths instead of showers. When asked why she was not receiving showers, the CLN stated she was not sure and would check for refusals, but later stated there was no proof that the resident refused the showers.
Unsecured hazardous items and unlocked carts/doors
Penalty
Summary
The facility failed to ensure the resident environment under its control was as free from accident hazards as possible. On 07/13/26, a white/green spray bottle of disinfectant/cleaner was observed on Resident #28’s bedside dresser in the resident’s room and was confirmed by housekeeping staff. The housekeeping staff removed the bottle and took it to the DON, who acknowledged the cleaner had been found in the room and stated she would check with the family to see if they had brought it into the facility. Additional observations showed multiple unsecured items and areas in resident-accessible spaces. On 07/12/26, a housekeeping cart near the Dining Room was left unattended and unlocked while residents entered and exited the area, and a laundry aide verified it needed to be locked. The same day, a door at the end of the service hall was observed unlocked with a case of water blocking the entrance, and it remained unlocked later that day; the Dietary Manager verified the door should be locked at all times. Also on 07/12/26, a treatment cart near the resident lounge was observed unlocked and unattended while residents were coming in and out of the lounge and passing by the cart, and an RN verified it should have been locked.
Inaccurate Wanderguard Orders and Documentation
Penalty
Summary
The facility failed to maintain accurate medical records related to a resident's wanderguard use. During record review, Resident #42 was found still wearing a wanderguard even though the order for the device had expired at the end of the prior month. The chart showed orders to check the placement and function daily and document this in the MAR, and staff had been documenting the checks, but the documentation was filed under an area that reflected the expiration. The DON confirmed that the wanderguard on the resident was not expired, but the orders in the record were incorrect and had only just been updated.
Insufficient Nursing Staffing and Delayed Call Light Response
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet resident needs and failed to ensure a licensed nurse was in charge on each shift. During a resident council meeting, 12 of 13 members reported that call light response times were very long, and when asked about the average wait time, the group stated it was longer than 45 minutes most days. This concern had been noted in almost every resident council meeting since the beginning of the year. A surveyor later overheard a worker telling a resident, "I'm sorry we are short staffed and it's taking so long to get to y'all," and the Administrator later confirmed staffing issues and stated they were working to address the concerns through new hiring and better deployment of current staff.
Inaccurate Daily Nursing Staffing Posting
Penalty
Summary
The facility failed to ensure the daily nursing staffing posting was completed accurately for two days during the survey process. On 07/12/26, surveyors observed the posted staffing data and found that the required resident census was not documented for 07/11/26 or 07/12/26. During an interview on 07/12/26 at 11:40 AM, RN #69 confirmed that the census had not been documented.
Failure to Maintain Safe Water Temperatures in Resident Rooms
Penalty
Summary
The facility failed to ensure that the resident environment was as free from accident hazards as possible, specifically regarding excessively high water temperatures in resident rooms. During interviews and inspections, a resident reported that the water was too hot and required staff assistance to adjust the temperature, although she had not been burned. Direct inspection by the surveyor confirmed that the water temperature at the resident's sink was uncomfortably hot. Further temperature checks conducted with the Maintenance Director revealed sink water temperatures ranging from 118 to 128 degrees Fahrenheit in multiple rooms, with the Maintenance Director acknowledging the high readings and noting that the temperature would decrease if the water was left running. These findings indicate that the facility did not adequately control water temperatures in resident areas, creating a potential accident hazard.
Lack of Competency Evaluations for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides had completed competency evaluations, as evidenced by the absence of such evaluations in the staff files for five nurse aides. During a review of staff records, no competency evaluations were found for these individuals. An interview with the Consulting Administrator confirmed that the facility was behind on completing competencies and that there were no records of competency evaluations for these nurse aides within the past year.
Deficiencies in Kitchen Sanitation, Food Storage, and Equipment Maintenance
Penalty
Summary
During an initial kitchen tour, surveyors observed that the walk-in refrigerator and freezer did not have documented temperature logs, and a large box of cookie dough in the freezer was left open to the air. In the resident pantry, a drawer was found to be dirty and littered with sugar, salt, and pepper, and an upper cabinet contained a box of oatmeal that was expired. The Infection Preventionist confirmed both the expired oatmeal and the unclean drawer. Additionally, the kitchen's ice machine was found to be missing the required water filter as specified by the manufacturer's guidance, a fact confirmed by the Maintenance Director. These findings indicate failures in maintaining a clean and sanitized kitchen environment, proper food storage, and equipment maintenance, as required by professional standards for food service safety.
Multiple Infection Control Failures in Linen, Food Service, and Hygiene Practices
Penalty
Summary
Facility staff failed to maintain proper infection prevention and control practices in several key areas. Clean linen was mishandled, with staff returning linen that had fallen on the floor back to the cart, and personal items such as sweaters, hand lotion, air freshener, topical medications, and hand sanitizer were found stored with clean linens on multiple occasions. Soiled briefs were observed in trash cans in shared bathrooms, and bags of trash and linen were left on the floor in multiple hallways, with linen barrels overflowing in the soiled utility area. Additionally, dirty plate covers and breakfast trays were placed on meal carts with clean lunch trays during meal service, and dinner trays were left at the nurse's station overnight. Washing machine filters in the laundry room were not cleaned daily as required. Staff also failed to follow infection control protocols when handling food trays and trash, and did not provide residents with hand hygiene before meals. For example, a CNA did not offer to wash or sanitize a resident's hands before serving breakfast. These lapses in infection control practices were confirmed by interviews with staff, including RNs, CNAs, the DON, and the laundry supervisor, who acknowledged the deficiencies and improper handling of linens, trash, and food service items.
Failure to Maintain Clean and Homelike Environment Due to Inadequate Housekeeping and Maintenance
Penalty
Summary
The facility failed to maintain a homelike, clean, and safe environment for its residents by not providing adequate housekeeping and maintenance services. Multiple resident rooms and common areas were observed to have unfinished drywall, bulging and stained walls, cracked tiles, overflowing trash cans, and brown substances present in bathrooms and on ceilings. These conditions were confirmed by staff during interviews, who acknowledged the presence of unfinished repairs, unclean bathrooms, and the need for maintenance intervention. Specific observations included a three-foot section of unfinished drywall above beds, rips in wallpaper, yellowish stains around toilets, and overflowing trash cans in shared bathrooms. Additionally, the shower room had ceiling tiles with brown substances, and several resident bathrooms had bulging walls with brown stains and cracked tiles. A resident reported ongoing issues with dark spots on the ceiling in their room, which had been repeatedly requested to be painted over several months, as documented in resident council meeting minutes. The Maintenance Director confirmed that several rooms and the shower room required repairs and replacement of ceiling tiles. The lack of timely response to maintenance requests and the presence of unsanitary and unfinished conditions throughout the facility contributed to the failure to provide a clean, comfortable, and homelike environment for residents.
Survey Results Not Readily Accessible to Residents and Families
Penalty
Summary
The facility failed to post the results of its most recent survey in a location that was readily accessible to residents, family members, and legal representatives. During two separate observations, survey results were not found on the bookshelf or anywhere else in the lobby, despite signage indicating their location. When interviewed, the Administrator was unable to locate the survey book in the designated area and later found it in the business office, confirming that it was not accessible as required.
Failure to Secure Resident Medical Records in Public Hallway
Penalty
Summary
The facility failed to secure and protect residents' personal and medical information, as multiple documents containing identifiable health information were found in an acrylic wall file holder mounted in a hallway outside the nursing office. On the date of observation, these documents included resident names, room numbers, diagnoses, code status, vital signs for twenty-nine residents, prescription information for a newly admitted resident, medication listings for thirty-one residents, and a controlled drug administration record. Additionally, shift change controlled substance inventory count sheets were present. The Director of Nursing confirmed that the documents had been placed in the file holder with the blank side facing up, but acknowledged their presence in a heavily trafficked area where they were accessible to anyone.
Inaccurate MDS Discharge Status Documentation
Penalty
Summary
The facility failed to accurately document a resident's discharge status in the Minimum Data Set (MDS) assessment. Record review showed that the MDS for a resident was coded as discharge to a short-term general hospital, while a Social Services note indicated that the resident was actually picked up by their daughter to be taken home, with arrangements made for home health services and a medical appointment at the VA Medical Center. During an interview, the MDS Coordinator confirmed that the MDS was incorrectly marked as discharge to hospital instead of discharge to home, reflecting an inaccurate assessment of the resident's status during the observation period.
Failure to Follow Physician's Order for Oxygen Therapy
Penalty
Summary
A resident who was somewhat hard of hearing and receiving oxygen therapy was observed multiple times with her oxygen concentrator set at 4 liters per minute, despite a physician's order specifying oxygen at 2 liters per minute by nasal cannula. The discrepancy was noted during several observations over two consecutive days, with the oxygen flow rate remaining at 4 liters per minute throughout this period. Record review confirmed the physician's order for 2 liters per minute, and staff interviews verified that the oxygen was not set according to the prescribed rate prior to correction.
Failure to Accurately Update Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to update its Daily Nurse Staffing Forms to accurately reflect the actual hours worked by registered nurses, licensed practical nurses or licensed vocational nurses, and certified nurse aides for five reviewed days. Record review and staff interview confirmed that the posted staffing information did not match the actual hours worked by direct care staff on those days. The Consulting Administrator acknowledged that the daily staff postings were not edited to reflect the true hours worked by nursing staff responsible for resident care.
Failure to Routinely Offer and Provide Evening Snacks to Residents
Penalty
Summary
The facility failed to provide evidence that evening snacks were routinely offered to residents, as required. During a resident council meeting, multiple cognitively intact residents reported that staff do not ask if residents want an evening snack. Residents stated that snacks are only provided if specifically requested, and the available options are limited, typically to graham crackers or snack cakes. One resident recalled only being offered an evening snack on a single occasion and expressed excitement about receiving it, while council members agreed that staff do not proactively offer snacks in the evening. An interview with the Dietary Manager confirmed that snacks ordered by a physician are prepared in advance, and the pantry is stocked daily with a rotating selection of snack cakes. For residents without physician-ordered snacks, only these limited options are available, and any special requests must be entered into the computer system at least one day prior. No other snacks are available after the kitchen closes in the evening, further limiting access for residents who may want snacks outside of scheduled meal times.
Improper Storage and Disposal of Garbage and Medical Supplies
Penalty
Summary
The facility failed to properly store garbage and refuse, as observed in the dumpster area where the lids were left open and the surrounding area was polluted with garbage and used medical supplies. This was confirmed during an interview with the Maintenance Director, who verified the presence of trash and medical supplies on the ground around the dumpster. The deficiency had the potential to affect all 61 residents residing in the facility at the time of the observation.
Failure to Cover Catheter Bags Compromises Resident Dignity
Penalty
Summary
Surveyors observed that the facility failed to maintain residents' dignity and respect by not covering urinary catheter bags for two residents. One resident was seen in bed with an uncovered, half-full catheter bag hanging off the foot of the bed in clear view of anyone passing by. A nurse confirmed that the catheter bag should have been covered. Another resident was observed moving through the hallway in a wheelchair with an uncovered catheter bag in his lap. This resident stated he had never been offered a cover for his catheter bag and expressed a desire to have one. A registered nurse acknowledged that the resident did not have a cover for his catheter bag. These observations demonstrate that the facility did not ensure catheter bags were covered and not openly displayed, as required to uphold residents' rights to dignity and respect.
Failure to Honor Resident Choice in Morning Care and Routine
Penalty
Summary
The facility failed to honor and facilitate resident self-determination by not supporting resident choice regarding waking time and morning care. One resident expressed a preference for early morning care and having her bed made before breakfast, but consistently did not receive assistance until after 10:00 AM, despite her requests and those of her family. Observations confirmed that morning care was provided much later than the resident's stated preference, and the resident's care plan did not initially reflect her wishes. The Director of Nursing acknowledged the resident's right to choose the timing of morning care but did not ensure this preference was honored prior to the deficiency being identified. Another resident also preferred to have her bed made and to get ready early in the day, but staff did not assist her until later, citing other responsibilities. This resident's preferences for her morning routine were not documented in her records, and she was observed attempting to make her own bed and get dressed without staff assistance. The lack of documentation and staff response resulted in the resident not receiving care according to her preferences.
Failure to Complete and Document Grievance Investigation
Penalty
Summary
The facility failed to ensure that all written grievance decisions included the required elements as outlined in their grievance policy. Specifically, a grievance form dated 4/10/2024 for one resident was not completed, and the incident was not logged into the grievance log. During record review, it was found that the grievance form was missing, and the administrator confirmed that a completed copy could not be located. The facility's policy requires the grievance officer to oversee grievances through conclusion, including conducting investigations and issuing written decisions, but this process was not followed for the identified grievance.
Failure to Investigate and Report Injuries and Allegations of Neglect
Penalty
Summary
The facility failed to follow its written policies and procedures regarding the investigation and reporting of injuries of unknown origin and allegations of neglect. In one instance, a resident was observed with a large bruise on her left upper arm, which she could not explain. The DON was initially unaware of the injury and, after being informed, had the nurse practitioner assess the bruise. The assessment confirmed new bruising of unknown cause. Despite facility policy requiring investigation and timely reporting of such injuries, the DON confirmed that no investigation or report was made to the appropriate authorities. In another case, a family member reported that a resident developed new Moisture Associated Skin Damage (MASD) and was not receiving regular baths. The family member filed complaints with the facility, APS, and the state licensing office. The facility did not document the complaint in its grievance log and delayed initiating an investigation until several months later. Additionally, the facility failed to submit required reports to the state licensing office regarding the allegation of neglect and the subsequent investigation, only doing so after being prompted during the survey process.
Failure to Timely Report and Investigate Alleged Abuse and Neglect
Penalty
Summary
The facility failed to timely report and investigate allegations of abuse and neglect for two residents. In the first case, a resident was observed with a large, unexplained bruise on her left upper arm. The DON was initially unaware of the injury and, after being informed, had the nurse practitioner assess the bruise. The assessment noted new bruising of unknown cause, but the DON confirmed that no investigation or report was made regarding this injury of unknown origin, despite facility policy requiring such actions for unexplained injuries. In the second case, a family member reported to authorities that a resident had developed pressure ulcers and was not receiving regular baths. The facility conducted an internal investigation and communicated with Adult Protective Services (APS), but failed to submit the required reports to the Office of Health Facility Licensure and Certification (OHFLAC) within the mandated timeframe. The initial report to OHFLAC was only submitted after the issue was identified during a survey review, indicating a lapse in timely reporting of the neglect allegation and investigation results.
Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
A large bruise of unknown origin was observed on the left upper arm of a resident, who was unable to explain how the injury occurred. The Director of Nursing (DON) was initially unaware of the bruise and only arranged for a Nurse Practitioner (NP) to assess the injury after it was brought to her attention. The NP's assessment documented new bruising of unknown cause on the resident's upper arms, with the resident denying any pain. The resident also had old bruises on her hands, likely from previous IV insertion sites. Despite the facility's policy requiring investigation and reporting of injuries of unknown origin, the DON confirmed that she did not report or investigate the incident as required. The policy specifically defines injuries of unknown source and mandates that such events be investigated to determine if abuse or neglect is suspected, and reported to appropriate authorities within specified timeframes. The failure to follow these procedures resulted in the deficiency.
Failure to Provide Scheduled Showers and ADL Assistance
Penalty
Summary
The facility failed to provide assistance with activities of daily living (ADLs) according to the assessed needs of a dependent resident. During an interview and observation, a resident reported not receiving showers or baths as ordered or preferred, expressing dissatisfaction with her hygiene, especially when receiving visitors. The resident was observed to have very oily hair at the time of the interview. A review of the resident's ADL documentation over a 30-day period revealed only one shower and two bed baths were provided. The facility administrator confirmed there was no documentation showing that the resident received showers as scheduled.
Failure to Provide Timely Incontinence Care and Assessments
Penalty
Summary
Facility staff failed to implement protocols to ensure that dependent residents received incontinence assessments and care at the required intervals. A resident who was incontinent and dependent on staff for care was not checked or provided incontinence care in a timely manner. The resident's Medical Power of Attorney (MPOA) reported that she frequently found the resident soiled upon her arrival and had to clean him herself, indicating that staff were not assessing or addressing the resident's incontinence needs regularly. Record review showed documentation that the resident was assessed for incontinence, but further investigation revealed that after an initial check at 7:00 AM, no additional assessments were recorded for the remainder of the morning. The nursing assistant assigned to the resident confirmed that checks should occur every two hours but admitted that no further checks had been performed after the initial morning assessment. The Director of Nursing also confirmed that residents should be checked at least every two hours.
Failure to Complete and Address Pharmacist Medication Regimen Reviews
Penalty
Summary
Surveyors found that the facility failed to ensure that a licensed pharmacist's monthly medication regimen reviews (MMRs) were completed and that any identified irregularities were reviewed and addressed by the attending physician, as required by facility policy. For two of five residents reviewed, there was no evidence that the physician responded to pharmacist recommendations regarding medication management. Specifically, for one resident, the MMR for December was missing, and the physician did not respond to a recommendation about blood pressure monitoring and medication instructions. For another resident, the MMR for December was also missing, and there was no physician response to a pharmacist's inquiry about the appropriate dosage of a topical medication. The Director of Nursing confirmed during interviews that the required documentation and physician responses were not available for these residents.
Failure to Provide Resident-Requested Breakfast Items
Penalty
Summary
A resident with a history of protein-calorie malnutrition, unintended weight loss, and a varied appetite repeatedly requested cereal and milk for breakfast, but did not receive it despite multiple requests from both the resident and her family member. The family member highlighted the cereal option on the resident's breakfast menu, and photographic evidence showed oatmeal was present, but not the requested cold cereal. The resident's care plan indicated she was at nutritional risk, required encouragement to eat, and was on a regular diet with dysphagia advanced texture and regular liquids, with house supplements provided three times daily. Despite the resident's tray ticket clearly listing both oatmeal and corn flakes, with these items bolded and underlined for emphasis, the resident did not receive the corn flakes on at least two observed occasions. Staff interviews confirmed the omission, with an RN stating that kitchen staff frequently forgot to include requested items on residents' trays, requiring nursing staff to retrieve missing items from the kitchen. The deficiency centers on the facility's failure to honor and implement the resident's stated food preferences, as documented and communicated, in accordance with her care plan and dietary orders.
Failure to Conduct Required Background Checks
Penalty
Summary
The facility failed to ensure that all staff had thorough background checks as required by the state of Virginia. Specifically, Nurse Aide (NA) #17 did not have a WV CARES eligibility letter on file, which is necessary to determine eligibility to work in a nursing home. NA #17 was hired on 05/08/06, and the WV CARES system became mandatory for all new and current employees starting in 2016. Despite this requirement, NA #17 continued to work at the facility without the necessary documentation. The Director of Nursing confirmed that NA #17 had been working prior to an illness and acknowledged the absence of the WV CARES eligibility screening documentation. This deficiency was identified during a review of five staff members' records, with NA #17 being the only one lacking the required documentation.
Failure to Provide RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was available for eight consecutive hours a day, seven days a week, which had the potential to affect all residents at the facility. A review of the facility staff postings and timecards revealed that on two specific dates, 11/19/23 and 12/03/23, no RN was scheduled or worked. During an interview, the Director of Nursing confirmed the absence of RN coverage on these dates and attributed it to being very short-staffed.
Failure to Retain Staff Posting Records
Penalty
Summary
The facility failed to retain the original staff postings for a minimum of 18 months as required by regulations. This deficiency was identified during a survey when the Director of Nursing (DON) was unable to provide the original Staff Posting Sheets for the first quarter of 2024. The issue was discovered on March 26, 2024, at 3:45 PM, and confirmed on March 27, 2024, at 9:10 AM, when the DON stated that the facility could not find the original documents. This failure had the potential to affect all 58 residents currently residing at the facility.
Improper Waste Containment in Dumpster Area
Penalty
Summary
The facility failed to properly contain waste in the dumpster area, affecting more than an isolated number of residents. Observations were made on three separate occasions, revealing trash scattered around the dumpster and in the community yard between the dumpster and the city road. The trash included used gloves, masks, cigarette packages, and cigarette butts. On March 25, 2024, at 1:05 PM, these items were observed around and behind the dumpster, extending from the fence to the city road. A second observation on March 26, 2024, at 11:10 AM confirmed the presence of similar waste in the same areas. A third observation on March 27, 2024, at 10:45 AM, conducted with the Administrator, again found trash around the dumpster and extending to the city road.
Failure to Support Resident Shower Preferences
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not supporting resident choices related to shower schedules. This deficiency was identified for seven residents, all of whom expressed dissatisfaction with the frequency and timing of their showers. Resident #26 reported receiving showers only once every two weeks despite requesting more frequent showers. Similarly, Resident #4 experienced infrequent showers and was not allowed to walk without assistance due to recent falls, which further limited her ability to shower as desired. Resident #3 expressed a preference for two to three showers per week but only received two showers in a three-week period. Resident #11's shower schedule conflicted with his preferred activities, such as Bingo, and he was not offered alternative shower times. Resident #12 was not given a choice between a shower or a bed bath, as outlined in her care plan, and received only two showers in the past month. Resident #36 reported inconsistent shower availability, with no showers documented in the past 14 days. Resident #1 also experienced delays in receiving showers and had only three showers documented in the past 30 days. The Director of Nursing acknowledged the ongoing issues with shower schedules and documentation, confirming that the facility was aware of the problem but had not yet resolved it. The lack of adherence to resident preferences and inadequate documentation contributed to the deficiency in promoting resident self-determination.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in their care. Resident #19, who was on a fluid restriction due to a renal diet, was observed receiving more fluids than prescribed, with no care plan in place to manage this restriction. Additionally, Resident #19, who is legally blind, did not have a care plan addressing her visual impairment in relation to her activities of daily living. Resident #24, who was prescribed Lasix for edema, also lacked a care plan to address this condition. Resident #50, diagnosed with Alzheimer's disease and dementia with behavioral disturbances, was prescribed medications to manage these conditions, yet there was no care plan in place to address the dementia or Alzheimer's disease. Furthermore, Resident #33, who has hemiplegia and hemiparesis following a cerebral infarction affecting the left side, expressed concerns about the placement of his call light, which was often out of reach due to his limited mobility. The care plan did not address the need for the call light to be placed on his right side, leading to increased anxiety for the resident.
Medication Administration and Monitoring Deficiencies
Penalty
Summary
The facility failed to administer medications as ordered by the physician for several residents, leading to significant delays in medication administration. For instance, a resident with a diagnosis of gangrene and diabetes received Gabapentin and Piperacillin-Tazobactam intravenously hours later than prescribed. Another resident with multiple sclerosis and diabetes experienced delays in receiving insulin, which was crucial for controlling blood glucose levels. These delays were acknowledged by the Director of Nursing, who confirmed that the medications were not administered within the facility's policy timeframe. In addition to medication administration issues, the facility did not complete required neurological checks following a resident's unwitnessed fall. The nursing staff failed to obtain vital signs at the specified intervals, missing several checks over a period of hours. This lapse was confirmed by the Director of Nursing, who agreed that the neurological evaluation flow sheet was incomplete. Furthermore, the facility did not report a critical oxygen saturation level to a physician for a resident with a history of congestive heart failure and atelectasis. The resident's oxygen level dropped to 85%, but there was no evidence that the physician was notified, which is a standard practice when such a critical level is observed. This oversight was confirmed by a registered nurse, who emphasized the importance of notifying a physician in such situations to potentially obtain an order for supplemental oxygen.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards, specifically regarding the security of medication carts. During an observation, a medication cart on the 400 Hall was found unlocked and unattended, which could allow unauthorized access to medications by residents or other individuals. The Director of Nursing confirmed the presence of medications in the cart and acknowledged that it should have been locked when unattended. An LPN noted that the lock on the cart was faulty, demonstrating how it could appear locked without actually being secure. The facility's policy mandates that medication carts must always be locked when out of sight or unattended, but this was not adhered to in this instance.
Failure to Monitor Medication Side Effects and Behaviors
Penalty
Summary
The facility failed to adequately monitor and document the side effects and behaviors associated with the administration of antianxiety and antidepressant medications for three residents. Resident #50, diagnosed with Alzheimer's disease, dementia with behavior disturbance, and anxiety disorder, was prescribed buspirone HCL to manage anxiety and restlessness. However, there was no documentation in the Medication Administration Record or progress notes regarding the monitoring of side effects such as sedation, morning hangover, ataxia, and nausea, as required by the physician's order. This lack of documentation was confirmed by the Director of Nursing (DON). Similarly, Resident #24, who had recurrent depressive disorder, dementia, Alzheimer's disease with late onset, psychotic disturbance, mood disturbance, and anxiety disorder, was prescribed duloxetine HCL and lorazepam. The facility failed to document the monitoring of side effects and behaviors as specified in the physician's orders for these medications. Additionally, for Resident #10, who was receiving lorazepam for seizures, the DON acknowledged that the monitoring records only indicated a simple 'yes' or 'no' without specifying the behaviors or side effects observed, which was insufficient for proper monitoring.
Failure to Provide Evening Snacks to All Residents
Penalty
Summary
The facility failed to provide a substantial and nourishing snack between the evening meal and breakfast, potentially affecting all residents without a dietary order for an evening snack or those unable to request one due to cognitive or physical limitations. During a resident council meeting, residents reported that the facility did not offer an evening snack, although they believed most residents would appreciate one. Some residents mentioned they could request a snack from the nurse's station if they were hungry before bedtime, but it was unclear if all residents knew how to do this. In a staff interview, an LPN working the evening shift confirmed that snacks were provided only to residents with a diagnosed need and a physician's dietary order. The LPN did not recall snacks being offered to all residents. A tour of the nutrition room revealed limited snack options, with only pre-packaged honey graham crackers available.
Infection Control Deficiency in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by two specific incidents. In the first incident, a resident was observed with gauze and tape around the left front of their wheelchair, which was intended to protect the resident's leg from rubbing against the wheelchair. However, the gauze and tape could not be cleaned, posing a potential infection risk. This was pointed out to a registered nurse, but no further information was provided by the Director of Nursing. In the second incident, a physical therapist assistant was observed performing therapy on a resident who was under transmission-based contact precautions for Clostridioides difficile (CDiff). Despite a sign indicating the need for appropriate personal protective equipment (PPE) and the use of soap and water instead of sanitizer, the assistant did not wear PPE and used hand sanitizer upon exiting the room. This was confirmed by both the assistant and the Director of Nursing, with no additional information provided.
Deficiencies in Resident Care and Rights
Penalty
Summary
The facility failed to treat a resident with respect and dignity by not assisting her with personal grooming, specifically the removal of facial hair. During a dining room observation, the resident was seen with noticeable facial hair, which she expressed a desire to have removed. The resident required supervision and personal assistance for personal hygiene, as indicated in her medical records. The issue was confirmed by the Administrator, who acknowledged the presence of the facial hair and stated that staff would address it. Later, the resident expressed happiness after the facial hair was removed, indicating the deficiency in timely personal care assistance. Additionally, the facility did not serve meals to residents in the dining room simultaneously, leading to staggered meal times at the same table. Observations showed significant delays in serving meals to residents seated at the same table, with some waiting up to 20 minutes longer than others. Staff interviews revealed that this was not the usual practice, but an issue in the kitchen caused the delay. Furthermore, the facility failed to ensure a resident's right to vote was upheld, as the resident was not asked about voting in the upcoming election, despite having a care plan that emphasized the importance of voting to him. The facility had no record of the resident voting in the 2020 election, although he had participated in previous elections.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was within reach for Resident #33, who had limited mobility due to a stroke affecting the left side of his body. During a resident council meeting, the resident expressed a preference for the call light to be pinned to his clothing or placed on the blanket beside him on the right side, as he was unable to reach it when it was placed on the left side. A subsequent observation confirmed that the call light was indeed placed on the left side, looped around the bed rail, and out of reach for the resident. This situation was confirmed by LPN #34, who acknowledged the call light's placement on the resident's nondominant side.
Failure to Notify Legal Guardian of Resident's Fall
Penalty
Summary
The facility failed to notify the legal guardian of a resident after the resident experienced a fall. The resident, who lacked the capacity to make medical decisions, had the West Virginia Department of Health and Human Resources (WV DHHR) appointed as their legal guardian. Despite this, the facility only attempted to contact the resident's son, leaving voicemail messages, but did not notify the legal guardian as required. The resident's fall was documented in the medical records, and the son was informed during a visit the following day, but there was no evidence that the WV DHHR was contacted. The deficiency was confirmed through a record review and staff interviews. The Director of Social Services acknowledged that the WV DHHR should have been contacted regarding any changes in the resident's condition. The Director of Nursing also indicated that the Change in Condition report should have reflected contact with the WV DHHR. However, the report only showed attempts to contact the resident's son, with no documentation of notification to the legal guardian, highlighting a failure in communication protocols for residents with legal guardians.
Privacy Breach in Resident Care and Information Handling
Penalty
Summary
The facility failed to maintain the personal privacy of a resident during catheter care. During an observation, a nurse aide did not close the door or window blinds while providing catheter care to a resident, compromising the resident's privacy. This incident was reported to the Director of Nursing, but no further information was provided. Additionally, the facility did not protect the confidentiality of residents' personal information. An elopement binder containing sensitive information, such as resident pictures, elopement risk identification forms, and admission record face sheets, was found unattended in the lobby. This binder was accessible to the public and contained personal details like dates of birth, distinguishing characteristics, and partial social security numbers of three residents. The facility administrator acknowledged this as a privacy issue, noting that the binder should have been kept in the front office.
Failure to Address Resident's Grievance Regarding Missing Wheelchair
Penalty
Summary
The facility failed to properly identify and address a grievance related to a resident's missing personal property, specifically a wheelchair provided by the veteran's administration. The grievance process, overseen by the social services department, was not followed as the verbal complaint made by the resident was not documented or tracked as a formal grievance. The resident had reported the missing wheelchair multiple times to various staff members, including nurses, activities staff, and aides, but did not receive any follow-up or resolution. The social worker responsible for the grievance process was unable to provide documentation of the grievance and assumed the issue was resolved when the wheelchair was initially found, but did not acknowledge the second instance of it going missing. During a resident council meeting, the resident expressed frustration over the lack of response and resolution regarding his missing wheelchair. Despite the facility's grievance policy requiring prompt acknowledgment and resolution of grievances, the resident's concerns were not addressed in a timely manner, and he was not kept informed of any progress. The social worker's failure to document and track the grievance led to a lack of communication and resolution, resulting in the resident's continued lack of access to his personal wheelchair.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 364 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Shepherdstown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Care Haven Center | 6.5 mi | ★★★★★ | 7 | 0 |
| Martinsburg Healthcare Center | 7.9 mi | ★★★★★ | 0 | 0 |
| South Mountain Rehab Center | 10.1 mi | ★★★★★ | 15 | 1 |
| Shenandoah Center | 10.2 mi | ★★★★★ | 10 | 0 |
| Willow Tree Healthcare Center | 11.2 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.